Appointments: 845.452.1700

Childrens Med Group

Online Patient Referral Request Form

Has the Doctor given you The Children's Medical Group Pink Referral/Testing Form? If yes please continue with the Online Request. If you have not received The Children's Medical Group Medical Group Pink Referral/Testing Form or if this is for a renewal of an existing referral please call the Referral department at (845)452-1700.

Notification To Parent/Guardian

The Referral Department will call you within 3 business days. If you do not hear from our referral Department in that time frame, please call to follow-up. The Referral Department does not schedule appointment unless instructed by the provider in an urgent situation.

Steps To Help Your Referral Process

Referrals to Specialist

  1. Check with your insurance company to see who is a participating specialist/vendor.
  2. Make your appointment and verify that the specialist/vendor is still a participating provider with you insurance.
  3. Some insurance companies require a referral form that must be generated by our Referral Department. MVP HMO, Aetna, USHC, Empire Blue Cross Blue Shield HMO, CDPHP Wellcare, GHI/HMO, Oxford HMO, as well as a few others require this.
  4. IF you company requires a special referral form, contact the Referral Department with the specialist name and phone number, as well as your appointment time and date so that we can generate the insurance referral. **If you go to an appointment and your referral is not there or you don’t have it in hand you will be charged by the specialist. Before being seen you should have received a copy of the referral by mail or if you had requested it to be faxed to the specialist check to see that the specialist has received it. If you have not received it by mail and the specialist doesn’t have it, call our office to make sure the referral has been done. In many cases we cannot backdate the referral and any chares due to the lack of a referral will be your responsibility as per the insurance company.**
  5. If you insurance does not require a special referral form you may take this form to the specialist’s office and nothing else will be needed.

Referrals For Testing

  1. If you were given this script/referral for a radiology x-ray or an Ultra/Sound you may go to any participating facility. Our referral department can direct you to participating facility. Only Pink script/referral is needed.
  2. If you were given a script for a Cat Scan or MRI please check with our referral department to see if prior authorization is needed. Most insurance companies require that these tests have prior authorizations. Our referral department will obtain the needed authorizations for you. After obtaining the authorization we will contact you so that you can write the authorization number on the pink script/referral. All you will need for your appointment is the pink script/referral with the authorization number. We cannot obtain the authorization after you have the procedure. If you go prior to having the authorization you will be responsible for any charges incurred.
  3. If you were given a pink script/referral for other testing such as EEG, EKG, sweat test, sleep studies, 24 hour halter monitor please contact the Referral Department as some of these test require a referral and/or prior authorization in addition to the pink script/referral, depending on the insurance company. Our referral department will help you make that determination.

    4. AGREE

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